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 ¤ Introduction
 ¤ Methods
 ¤ Results
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 Table of Contents     
ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 3  |  Page : 420-425
 

Minimally-invasive versus open pancreatoduodenectomies with vascular resection: A 1:1 propensity-matched comparison study


1 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
2 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Department of Anaesthesiology, Singapore General Hospital, Singapore
3 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke-National University of Singapore Medical School, Singapore

Date of Submission17-Jun-2021
Date of Acceptance09-Nov-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Brian K P. Goh
Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, 20 College Road, Academia
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.jmas_201_21

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 ¤ Abstract 


Background: Minimally invasive pancreatic pancreatoduodenectomy (MIPD) is increasingly adopted worldwide and its potential advantages include reduced hospital stay and decrease pain. However, evidence supporting the role of MIPD for tumours requiring vascular reconstruction remains limited and requires further evaluation. This study aims to investigate the safety and efficacy of MIPD with vascular resection (MIPDV) by performing a 1:1 propensity-score matched (PSM) comparison with open pancreatoduodenectomy with vascular resection (OPDV) based on a single surgeon's experience.
Methods: This is a retrospective review of 41 patients who underwent PDV between 2011 and 2020 by a single surgeon. After PSM, the comparison was made between 13 MIPDV and 13 OPDV.
Results: Thirty-six patients underwent venous reconstruction (VR) only and 5 underwent arterial reconstruction of which 4 had concomitant VR. The types of VR included 22 wedge resections with primary repair, 8 segmental resections with primary anastomosis and 11 requiring interposition grafts. Post-operative pancreatic fistula (POPF) occurred in 3 (7.3%) patients. Major complications (>Grade 2) occurred in 16 (39%) patients, of which 7 were due to delayed gastric emptying requiring nasojejunal tube placement. There was 1 (2.4%) 30-day mortality (OPDV). Of the 13 MIPDV, there were 3 (23.1%) open conversions. PSM comparison demonstrated that MIPDV was associated with longer median operative time (720 min vs. 485 min (P = 0.018). There was no statistically significant difference in other key perioperative outcomes such as intra-operative blood loss, overall morbidity, major morbidity rate, POPF and length of stay.
Conclusion: Our initial experience with the adoption MIPDV has demonstrated it to be safe with comparable outcomes to OPDV despite the longer operation time.


Keywords: Extended pancreatectomy, laparoscopic, pancreatoduodenectomy, robotic, vascular resection


How to cite this article:
Yang E, Chong Y, Wang Z, Koh YX, Lim KI, P. Goh BK. Minimally-invasive versus open pancreatoduodenectomies with vascular resection: A 1:1 propensity-matched comparison study. J Min Access Surg 2022;18:420-5

How to cite this URL:
Yang E, Chong Y, Wang Z, Koh YX, Lim KI, P. Goh BK. Minimally-invasive versus open pancreatoduodenectomies with vascular resection: A 1:1 propensity-matched comparison study. J Min Access Surg [serial online] 2022 [cited 2022 Jul 2];18:420-5. Available from: https://www.journalofmas.com/text.asp?2022/18/3/420/337608





 ¤ Introduction Top


At present, there is increasing adoption of minimally invasive pancreatic surgeries (MIPS) internationally since it was first reported two decades ago.[1] The uptake of MIPS has been slow owing to its technical complexity. However, improved knowledge, sharing of experiences, standardisation of techniques[2] and advancements in technology used in MIPS have expanded the role and adoption of MIPS globally.[3],[4] The indications for MIPS have hence increased from less complex procedures such as pancreatic enucleation and distal pancreatectomies (DP)[5] to now even more complicated ones such as central pancreatectomies and pancreatoduodenectomies (PD)[6] and increasingly, for pancreatectomies with vascular resections and reconstruction.[7],[8],[9],[10]

Despite evidence from numerous retrospective case–control studies as well as randomised trials in DP and PD[5],[11],[12] demonstrating superior short-term operative outcomes, the conventional open approach for pancreatic surgery remains the most common approach adopted by pancreatic surgeons today.[11],[13],[14],[15] The main concerns preventing further increased adoption of MIPS remains the long and steep learning curve required from surgeons to learn and attain proficiency.[16],[17] This is even more so when the conventional open approach is an already complex operation with high morbidity and complication rates as with MIPS. Robotic pancreatic surgery has been proposed as an alternative to traditional laparoscopic surgery, with reportedly increased advantages such as improved dexterity and stability potentially resulting in lower open conversion and post-operative pancreatic fistulas (POPF), especially during the early learning phase.[16],[18],[19]

In this study, we aimed to evaluate our experience with minimally invasive pancreatoduodenectomy with vessel resection (MIPDV) versus open PD with vessel resection (OPDV) in 41 patients who underwent PD with vessel resection from 2011 to 2020.


 ¤ Methods Top


Retrospective review of 41 consecutive patients who underwent PDV by a single surgeon between 2011 and 2020 were identified from a prospectively maintained database. The need for patient consent for this study was waived by the Singhealth Institution Review Board.

Clinicopathological data including patient demographics and relevant pre-operative, intra-operative and post-operative outcomes were obtained retrospectively from patient records. Clinical data were collected from a prospective computerised clinical database (Sunrise Clinical Manager version 5.8, Eclipsys Corporation, Atlanta, Georgia) and patient clinical charts while operative data was obtained from another prospective computerised database (OTM 10, IBM, Armonk, New York, USA).

The decision for MIPDV versus OPDV was not based on a formal protocol. The indications for MIPDV gradually expanded over the study period as the surgeon gained increasing experience with MIPS. In this early experience, cases requiring vascular reconstruction via end-to-end anastomosis and interposition graft were only planned for the hybrid procedure and open reconstruction.

Definitions

Extended pancreatectomy was defined according to the 2014 ISPGS definition.[20] Totally minimally invasive surgery (MIS) cases were defined as cases whereby both resection and reconstruction were performed laparoscopically or robotically. Hybrid procedures were cases whereby the resection was completed via MIS but the reconstruction (pancreaticojejunostomy, hepaticojejunostomy, gastrojejunostomy and vascular anastomoses) was performed via an open midline incision. Any procedure whereby the resection phase could not be completed via MIS was considered an open conversion.

Post-operative complications were classified according to the Clavien-Dindo grading system[21] and recorded regardless of the length of postoperative stay or, if the patient was discharged and readmitted, within a 30-day duration. Pancreatic fistulas were defined and graded according to the latest 2016 International Society of Grading of Pancreatic fistula.[22] Drain fluid amylase was routinely collected on post-operative day 3 and a value more than 3 times the concentration of the upper limit of serum amylase or a value more than 300 IU/L associated with a clinically relevant condition was considered a clinically relevant pancreatic fistula. Grade B pancreatic fistula included patients who had surgical drains kept in placed for more than 3 weeks or required endoscopic or percutaneous placement of new drains. Grade C pancreatic fistulas were fistulas which required reoperation, lead to organ failure or resulted in mortality. Purely asymptomatic fistulas previously referred to as a grade-A fistula were not classified as pancreatic fistula or morbidity but considered a biochemical leak.

Thirty-day mortality was defined as any death within 30 days from surgery and in-hospital mortality was defined as any death during the index hospital stay regardless of time from surgery. Thirty-day readmissions were defined as any admission into the hospital occurring within 30 days of discharge.

Statistical analysis

Propensity score matching (PSM) analysis was performed to minimise selection bias. Factors included in the PSM model were age, gender, ASA status, pre-operative biliary drainage, benign/malignant pathology, tumour size, type of pancreatectomy (pancreatoduodenectomy versus total pancreatectomy), MIS approach (totally MIS, hybrid or open conversion), presence of arterial resection and type of venous reconstruction (VR). PSM was performed by nearest neighbor matching in a 1:1 ratio without replacement, and analysis was performed between minimally invasive (MIPDV) and open (OPDV) pancreatoduodenectomy with vascular resection (PDV). Univariate analyses were performed using the Mann-U-Whitney test or Chi-squared tests as appropriate and P < 0.05 was considered statistically significant. All statistical analyses were performed using RStudio version 1.2.1335 (RStudio Team, R Studio, Boston, MA, USA).


 ¤ Results Top


The baseline demographics and operative details are summarised in [Table 1]. A total of 41 PDV was performed during the study period. One patient in the OPDV arm requiring arterial resection received neoadjuvant chemo-radiotherapy. There were 13 (31.7%) MIPDV (6 robotic-assisted) and 28 (68.3%) OPDV. Of the MIPDV cases, 6 cases (46.1%) were performed totally MIS (4 robotic-assisted), 4 cases (30.8%) were performed using a hybrid approach (2 robotic assisted) and 3 cases required conversion to open during the resection phase. Most of the cases involved venous resection only with 11 (84.6%) MIS cases and 25 (89.3%) open cases. Five patients underwent arterial resection with concomitant VRs. The types of VRs in the 41 patients included 9 MIPDV cases and 13 OPDV with a wedge resection of the portal vein with primary closure. One MIPDV and 7 OPDV cases underwent segmental resection with primary end-to-end anastomosis. Interposition grafts were performed in 3 MIPDV and 8 OPDV. All 6 cases of totally MIS MIPDV had wedge venous resection with primary closure. Two-hybrid cases underwent wedge resection with primary closure and 2 underwent interposition graft. Of the 3 MIPDV with open conversions, 2 required arterial reconstruction and 1 required an interposition graft.
Table 1: Baseline characteristics of all patients and comparison between minimally-invasive pancreatoduodenectomy with vascular resection versus open pancreatoduodenectomy with vascular resection

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PSM was used to select for a matched number of OPDV cases. The proportion of the number of cases with VR for wedge resection and primary repair, primary end-end anastomosis with patch and interposition graft are 8 (61.5%), 4 (30.8%) and 1 (7.7%) respectively. Similarly, the proportion of cases for OPDV cases were subjected to PSM, 10 (76.9%) of cases had a PD whereas 3 (23.1%) had a total pancreatectomy. Most cases 10 (76.9%) involved venous resection.

Outcomes between minimally invasive pancreatoduodenectomy with vessel resection versus open pancreatoduodenectomy with vascular

The outcomes for patients undergoing MIPDV versus OPDV are summarised in [Table 2]. MIPDV patients had a statistically significant longer median operative time of 720 min whilst the median time for OPDV was 492.5 min (P = 0.005). This was similar after PSM with a median time of 485 min in propensity score-matched OPDV cases (P = 0.182). There was no statistically significant difference in median estimated blood loss and intra-operative blood transfusions. In terms of clinically significant post-operative complications classified, there was no statistically significant difference in Clavien Dindo grade 3–5 complications in the MIPDV versus OPDV groups. Likewise, patients in the MIPDV group had no significant difference in terms of median post-operative hospital stay, 30-day re-admissions, in-hospital and 30-day mortality. Five patients (13.9%) in the OPDV group had an unplanned reoperation for complications. These included 3 re-operations for post-pancreatectomy haemorrhage and 2 for vascular thromboses (1 venous thrombosis and 1 arterial thrombosis). Both patients with vascular thromboses underwent revision of the anastomoses (1 from primary venous anastomosis to interposition graft, 1 revision of the arterial anastomosis). In the MIPDV group, two patients (15.4%) needed reoperations, 1 for internal herniation of the biliopancreatic limb and the other for interposition venous graft thrombosis. Open intra-operative thrombectomy was performed followed by post-operative anticoagulation to manage the graft thrombosis.
Table 2: Perioperative outcomes of all patients and comparison between minimally-invasive pancreatoduodenectomy with vascular resection versus open pancreatoduodenectomy with vascular resection

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 ¤ Discussion Top


At present, evidence supporting the role of MIPD over OPD remains mixed. Four randomised control trials[13],[23],[24],[25] have been published to date comparing laparoscopic PD (LPD) over OPD.[23] Three of these studies demonstrated some short-term advantages associated with LPD over OPD[13],[23],[24] whereas 1 study, the LEPOARD-2 trial[25] was terminated early due to safety concerns arising from the increased mortality observed with LPD. However, these trials did not analyse patients who underwent MIPDV and data on the outcomes of MIPDV remain limited today.

In the present study, we have demonstrated that MIPDV can be adopted safely with no statistically significant difference in terms of key post-operative outcomes including morbidity and mortality compared to OPDV. Concordant with the literature, while MIPDV was associated with significantly longer median operative times as compared to OPDV,[26] in our experience this did not result in higher morbidity rates. An early series by Croome et al. from the Mayo Clinic[8] evaluated MIPDV compared to OPDV which demonstrated that MIPDV was associated with a lower intra-operative blood loss, shorter length of hospital stay and no significant difference in the total number of or severe complications and 30-day mortality compared to OPDV. Furthermore, the investigators[8] also found that the oncologic outcomes in terms of R0 resection was higher in the laparoscopic versus open group. This was attributed possibly due to better visualisation and magnification with laparoscopy allowing for more detailed lymphadenectomy and tumour resection.[8] A more recent study by Shyr et al demonstrated that robotic PD with vascular resection and the reconstruction resulted in acceptable vessel patency rates with good oncologic and clinical outcomes.[9] In the present study, although MIPDV was associated with longer median operative times, it is expected that the operative times would decrease with increasing experience as we progress along the learning curve.[27] Of note, there was no statistically significant difference in the estimated blood loss and intra-operative blood transfusion between MIPDV and OPDV. Overall, while our study did not demonstrate the benefit of the decreased intra-operative blood loss as reported by Croome et al., we surmised that this was likely due to this representing our initial experience whereby the surgeon was mounting the steep learning curve associated with MIPDV. Nonetheless, we have demonstrated that MIPDV can be adopted safely and is not associated with an increased risk of intra-operative bleeding or post-operative complications.

POPF is the most important and one of the most frequent complications after PD and remains the Achilles heel of the procedure. Construction of the pancreatic anastomoses is one of the major obstacles for surgeons to embark on MIPD. However, in the present study, there were no cases of clinically-significant POPF associated with MIPDV. This was consistent with the results by Wang et al.[24] which demonstrated that MIPD was not inferior to open surgery in terms of Grades B and C POPF. One of the major reasons for the low POPF rate is that MIPDV is usually performed in the setting of a firm pancreas with a dilated pancreatic duct resulting in a low risk of developing POPF.

More recently, some authors have proposed the use of robotic surgery for reconstruction after pancreatoduodenectomy[28] due to the theoretical superiority of the robot in terms of dexterity and increased degrees of freedom possible with robotic surgery.[18] This was supported by the study by Watkins et al.[28] which demonstrated that robotic reconstruction of the pancreatic anastomoses during the learning curve did not result in an increase in anastomotic complications such as POPF. The recent study by Kauffman et al.,[29] further demonstrated the feasibility of robotic-assisted PD with vascular resection and reconstruction. The authors reported low rates of open conversion and intra-operative blood transfusions. It has been postulated that with the better ergonomics and improved 3D visualisation from robotic surgery,[30] this would result in many advantages to the operating surgeon, especially for highly complicated procedures such as, robotic-assisted PDV resection. Nonetheless, it is important to highlight that MIPDV should be undertaken with caution only by surgeons with extensive prior experience with both open and MIS pancreatic surgery due to the complexity of the procedure including vascular reconstruction. Surgeons should have ideally already mounted the learning curves for standard MIPD. It is important to highlight that in this early experience, all 6 cases of totally MIPDV were performed for wedge resections with primary venous repair and all 7 MIPDV cases requiring venous and arterial anastomoses in this series were performed via the open technique either via the hybrid approach or after open conversion. Although previous authors in small case series (8–10) have reported the feasibility of performing vascular anastomoses via laparoscopic or robotic surgery, we elected to perform the vascular anastomoses via the open technique to ensure the safety of patients during this early experience.


 ¤ Conclusion Top


Our initial experience with MIPDV demonstrated that it can be adopted safely by experienced surgeons with no significant difference in short-term perioperative outcomes compared to OPDV. Further studies preferably in the form of a multi-centre randomised control trial are needed to determine the role and potential advantages of MIPDV.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Gagner M, Pomp A, Herrera MF. Early experience with laparoscopic resections of islet cell tumors. Surgery 1996;120:1051-4.  Back to cited text no. 1
    
2.
Hogg ME, Besselink MG, Clavien PA, Fingerhut A, Jeyarajah DR, Kooby DA, et al. Training in Minimally Invasive Pancreatic Resections: A paradigm shift away from “See one, Do one, Teach one”. HPB (Oxford) 2017;19:234-45.  Back to cited text no. 2
    
3.
Lianos GD, Christodoulou DK, Katsanos KH, Katsios C, Glantzounis GK. Minimally invasive surgical approaches for pancreatic adenocarcinoma: Recent trends. J Gastrointest Cancer 2017;48:129-34.  Back to cited text no. 3
    
4.
Vollmer CM, Asbun HJ, Barkun J, Besselink MG, Boggi U, Conlon KC, et al. Proceedings of the first international state-of-the-art conference on minimally-invasive pancreatic resection (MIPR). HPB (Oxford) 2017;19:171-7.  Back to cited text no. 4
    
5.
de Rooij T, van Hilst J, van Santvoort H, Boerma D, van den Boezem P, Daams F, et al. Minimally invasive versus open distal pancreatectomy (LEOPARD): A multicenter patient-blinded randomized controlled trial. Ann Surg 2019;269:2-9.  Back to cited text no. 5
    
6.
Senthilnathan P, Gul SI, Gurumurthy SS, Palanivelu PR, Parthasarathi R, Palanisamy NV, et al. Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients. J Minim Access Surg 2015;11:167-71.  Back to cited text no. 6
    
7.
Low TY, Goh BKP. Initial experience with minimally invasive extended pancreatectomies for locally advanced pancreatic malignancies: Report of six cases. J Minim Access Surg 2019;15:204-9.  Back to cited text no. 7
    
8.
Croome KP, Farnell MB, Que FG, Reid-Lombardo KM, Truty MJ, Nagorney DM, et al. Pancreaticoduodenectomy with major vascular resection: A comparison of laparoscopic versus open approaches. J Gastrointest Surg 2015;19:189-94.  Back to cited text no. 8
    
9.
Shyr BU, Chen SC, Shyr YM, Wang SE. Surgical, survival, and oncological outcomes after vascular resection in robotic and open pancreaticoduodenectomy. Surg Endosc 2020;34:377-83.  Back to cited text no. 9
    
10.
Khatkov IE, Izrailov RE, Khisamov AA, Tyutyunnik PS, Fingerhut A. Superior mesenteric-portal vein resection during laparoscopic pancreatoduodenectomy. Surg Endosc 2017;31:1488-95.  Back to cited text no. 10
    
11.
van Hilst J, de Rooij T, Klompmaker S, Rawashdeh M, Aleotti F, Al-Sarireh B, et al. Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): A pan-European propensity score matched study. Ann Surg 2019;269:10-7.  Back to cited text no. 11
    
12.
de Rooij T, Lu MZ, Steen MW, Gerhards MF, Dijkgraaf MG, Busch OR, et al. Minimally invasive versus open pancreatoduodenectomy: Systematic review and meta-analysis of comparative cohort and registry studies. Ann Surg 2016;264:257-67.  Back to cited text no. 12
    
13.
Poves I, Burdío F, Morató O, Iglesias M, Radosevic A, Ilzarbe L, et al. Comparison of perioperative outcomes between laparoscopic and open approach for pancreatoduodenectomy: The PADULAP randomized controlled trial. Ann Surg 2018;268:731-9.  Back to cited text no. 13
    
14.
Goh BK, Low TY, Koh YX, Lee SY, Teo JY, Kam JH, et al. Changing trends and outcomes associated with the adoption of minimally invasive pancreatic surgeries: A single institution experience with 150 consecutive procedures in Southeast Asia. J Minim Access Surg 2020;16:404-10.  Back to cited text no. 14
    
15.
Goh BK, Lee SY, Teo JY, Kam JH, Jeyaraj PR, Cheow PC, et al. Changing trends and outcomes associated with the adoption of minimally invasive hepatectomy: A contemporary single-institution experience with 400 consecutive resections. Surg Endosc 2018;32:4658-65.  Back to cited text no. 15
    
16.
Goh BK, Low TY, Lee SY, Chan CY, Chung AY, Ooi LL. Initial experience with robotic pancreatic surgery in Singapore: Single institution experience with 30 consecutive cases. ANZ J Surg 2019;89:206-10.  Back to cited text no. 16
    
17.
Goh BK, Teo RY. Current status of laparoscopic and robotic pancreatic surgery and its adoption in Singapore. Ann Acad Med Singap 2020;49:377-83.  Back to cited text no. 17
    
18.
Goh BK, Low TY, Teo JY, Lee SY, Chan CY, Chow PK, et al. Adoption of robotic liver, pancreatic and biliary surgery in Singapore: A single institution experience with its first 100 consecutive cases. Ann Acad Med Singap 2020;49:742-8.  Back to cited text no. 18
    
19.
Goh BK, Chan CY, Soh HL, Lee SY, Cheow PC, Chow PK, et al. A comparison between robotic-assisted laparoscopic distal pancreatectomy versus laparoscopic distal pancreatectomy. Int J Med Robot 2017;13.  Back to cited text no. 19
    
20.
Hartwig W, Vollmer CM, Fingerhut A, Yeo CJ, Neoptolemos JP, Adham M, et al. Extended pancreatectomy in pancreatic ductal adenocarcinoma: Definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). Surgery 2014;156:1-14.  Back to cited text no. 20
    
21.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 21
    
22.
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017;161:584-91.  Back to cited text no. 22
    
23.
Palanivelu C, Senthilnathan P, Sabnis SC, Babu NS, Srivatsan Gurumurthy S, Anand Vijai N, et al. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. Br J Surg 2017;104:1443-50.  Back to cited text no. 23
    
24.
Wang M, Li D, Chen R, Huang X, Li J, Liu Y, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: A multicentre, open-label, randomised controlled trial. Lancet Gastroenterol Hepatol 2021;6:438-47.  Back to cited text no. 24
    
25.
van Hilst J, de Rooij T, Bosscha K, Brinkman DJ, van Dieren S, Dijkgraaf MG, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): A multicentre, patient-blinded, randomised controlled phase 2/3 trial. Lancet Gastroenterol Hepatol 2019;4:199-207.  Back to cited text no. 25
    
26.
Goh BK, Teo JY, Chan CY, Lee SY, Cheow PC, Chow PK, et al. Evolution of laparoscopic liver resection at Singapore General Hospital: A nine-year experience of 195 consecutive resections. Singapore Med J 2017;58:708-13.  Back to cited text no. 26
    
27.
Daouadi M, Zureikat AH, Zenati MS, Choudry H, Tsung A, Bartlett DL, et al. Robot-assisted minimally invasive distal pancreatectomy is superior to the laparoscopic technique. Ann Surg 2013;257:128-32.  Back to cited text no. 27
    
28.
Watkins AA, Kent TS, Gooding WE, Boggi U, Chalikonda S, Kendrick ML, et al. Multicenter outcomes of robotic reconstruction during the early learning curve for minimally-invasive pancreaticoduodenectomy. HPB (Oxford) 2018;20:155-65.  Back to cited text no. 28
    
29.
Kauffmann EF, Napoli N, Menonna F, Genovese V, Cacace C, Andrea CI, et al. Robot-assisted pancreaticoduodenectomy with vascular resection: Technical details and results from a high-volume center. Laparosc Surg 2020;4:37. Available from: https://ls.amegroups.com/article/view/6081. [Last accessed on 2021 May 15].  Back to cited text no. 29
    
30.
Wee IJY, Kuo LJ, Ngu JC. A systematic review of the true benefit of robotic surgery: Ergonomics. Int J Med Robot 2020;16:e2113.  Back to cited text no. 30
    



 
 
    Tables

  [Table 1], [Table 2]



 

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